Norman Saffra

Laser in situ keratomileusis-induced optic neuropathy.

OBJECTIVE To report a case of bilateral optic neuropathy after bilateral laser-assisted in situ keratomileusis (LASIK) surgery. DESIGN Observational case report. METHODS Complete eye examination with detailed evaluation of the optic nerve, detailed medical history, stereo disc photographs, GDx Nerve Fiber Analyzer testing, Humphrey 24-2 SITA visual field testing, diurnal intraocular pressure measurement, serologic evaluation, and magnetic resonance imaging of the brain and orbits. MAIN OUTCOME MEASURES Optic nerve status, visual field status, and visual acuity. RESULTS A subject with previously healthy optic nerves had bilateral optic neuropathy develop after LASIK surgery. This neuropathy manifested with a subjective decrease in visual field, normal visual acuity, normal color vision, relative afferent pupillary defect, increased cupping of the optic nerve with focal neuroretinal rim defects, decreased nerve fiber layer thickness, and nerve fiber bundle-type visual field defects. The subject had no other risk factors for optic neuropathy. No other cause of neuropathy was identified. CONCLUSIONS Optic neuropathy is a potential vision-threatening complication of LASIK surgery. This complication may be due to barotrauma or ischemia related to extreme elevation of intraocular pressure by the suction ring. Careful examination of the optic nerve before and after LASIK surgery is warranted.

Baylisascaris Procyonis Neural Larva Migrans in an Infant in New York City.

Neural larva migrans (NLM) with eosinophilic meningoencephalitis secondary to raccoon roundworm (Baylisascaris procyonis) infection has been reported in rural and suburban areas of North America and Europe with extant raccoon populations. Most cases have occurred in infants less than two years of age exposed to areas of raccoon fecal contamination. Here, we present a case of Baylisascaris-induced NLM from the densely populated borough of Brooklyn in New York City and alert urban pediatricians to consider this cause of clinical neurologic disease even in areas not typically thought to be associated with endemic risk factors. Infected raccoons also occur in urban settings, and urban children may be exposed to environmental areas or materials contaminated with their feces and the parasites eggs.

Vancomycin-Resistant Enterococcal Endophthalmitis

V ancomycin-sensitive enterococcal acute endophthalmitis has been reported following cataract extraction, penetrating keratoplasty, trabeculectomy, and pupilloplasty. However, vancomycinresistant enterococcal (VRE) endophthalmitis has been described in only 3 patients to date: an immunocompromised, hospitalized patient with underlying bacteremia, an immunocompetent patient following keratoplasty with infected donor tissue, and an immunocompetent patient 20 years following trabeculectomy. We report the first case, to our knowledge, of postcataract VRE endophthalmitis.

Laser in situ keratomileusis as treatment for anisometropia after scleral buckling surgery

Scleral buckling is an excellent procedure for retinal reattachment but can induce disabling refractive errors. Laser in situ keratomileusis (LASIK) has been proven effective for the reduction of refractive errors induced by ophthalmic surgery. We describe the case of a 53-year-old man who developed symptomatic anisometropia after placement of a scleral buckle for repair of a rhegmatogenous retinal detachment (RD). After the scleral buckling procedure, he retained excellent best corrected visual acuity but could not tolerate spectacle or contact lens correction. Thirty-four months after the scleral buckling procedure, LASIK was performed to correct myopic astigmatism with excellent refractive and functional results. This case demonstrates that LASIK may be safe and effective for the correction of refractive errors induced by RD repair.

Post traumatic polymicrobial endophthalmitis, including neisseria subflava

DESIGN To report the second known case of post-traumatic endophthalmitis caused by Neisseria subflava. DESIGN Interventional case report. METHODS A two-year-old child with post-traumatic corneal laceration and uveal prolapse required medical and surgical therapy for endophthalmitis caused by multiple organisms including N. subflava. RESULTS After aggressive therapy, patient had a favorable outcome without vision compromise. CONCLUSIONS As there is still not a standard protocol for therapy for post-traumatic endopthalmitis, we recommend the use of broad-spectrum antibiotics via intravitreal, intravenous, and topical routes. Consideration of typical and unusual bacteria that have been reported to cause endopthalmitis, as well as the source of injury, should guide antibiotic choice.

Argon Laser Photocystotomy of a Vitreous Cyst

Free-floating idiopathic vitreous cysts are rare entities. For symptomatic patients, treatment options include laser photocystotomy or pars plana vitrectomy (PPV) with cyst excision. Historically, size of the cyst impacted treatment approaches. Laser treatments have been used for smaller cysts ranging 3 to 5 mm in diameter. PPV has been utilized for cysts larger than 4 mm. Successful laser photocystotomy has been reported, utilizing both argon and Nd: YAG lasers. Herein, we present a case of successful argon laser photocystotomy of a 7.1 mm diameter vitreous cyst, the largest documented cyst ever treated. Treatment should be individualized based on patient age, ability to cooperate in an office setting, phakic status, status of the posterior hyaloid, cyst morphology, and location. In our case, because of pigment on the anterior cyst surface, and the presence of an attached posterior hyaloid, the argon green laser was used.

Acute diplopia as the presenting sign of silent sinus syndrome.

Silent sinus syndrome is a rare acquired condition that typically presents as enophthalmos and hypoglobus due to atelectasis of the maxillary sinus. The chronic negative pressure in the sinus slowly retracts the orbital floor, altering orbital anatomy and affecting the function of orbital contents. The authors present the first case of acute vertical diplopia as the presenting symptom of silent sinus syndrome.

Ocular Toxoplasmosis: Controversies in Primary and Secondary Prevention

Ocular toxoplasmosis is the most common cause of posterior uveitis in the United States and worldwide. It commonly follows a relapsing course with the potential for multiple adverse visual sequelae and, rarely, blindness. Both immune-competent and immune-suppressed populations can develop severe relapsing disease. There is considerable debate regarding the initial treatment of ocular toxoplasmosis in both groups, with multiple antiparasitic agents commonly used with little evidence to support any particular regimen. The precise role of corticosteroids in treatment also has yet to be rigorously defined. Secondary prevention is commonly implemented in the immune suppressed population, but there is a lack of level one evidence to support its role in immune-competent patients, though it warrants future investigation.

Burkholderia cepacia endophthalmitis, in a penicillin allergic patient, following a ranibizumab injection

Burkholderia cepacia, a Gram-negative bacterium commonly found in water and soil, is a rare cause of endophthalmitis. The authors report a case of a penicillin-allergic patient who presented 15 days after an uneventful injection of ranibizumab for neovascular age-related macular degeneration with culture-positive B cepacia endophthalmitis. Initial antibiotic therapy using non-penicillin-based medications was not successful in eradicating the bacteria. Subsequent treatment with a third-generation cephalosporin resulted in complete resolution of the infection. B cepacia should be included among the bacterial species that may cause endophthalmitis after intravitreal injections.

In vitro analysis of Nd:YAG laser damage to hydrophilic intraocular lenses.

BACKGROUND AND OBJECTIVE Damaged optics of an intraocular lens (IOL) can impair visual functioning. Damage can occur during the manufacturing process, during implantation, or during post-implantation Nd:YAG laser posterior capsulotomy. An in vitro experiment was performed to identify the potential IOL damage patterns associated with the use of the Nd:YAG laser for posterior capsulotomy. PATIENTS AND METHODS A review of the literature regarding Nd:YAG laser damage to IOLs was performed. The objectives were to describe the damage patterns to a sample IOL by performing virtual posterior capsulotomies. RESULTS Patterns of damage were demonstrated and described. CONCLUSION Although optic damage can occur with use of the Nd:YAG laser, it is infrequent and usually the result of improper depth of focus.